Standardizing Joint-Line Determination on Anteroposterior Knee Radiographs: Multicenter Validation of the Adductor Ratio and a Novel Composite Index in 3,000 Knees

Standardizing Joint-Line Determination on Anteroposterior Knee Radiographs: Multicenter Validation of the Adductor Ratio and a Novel Composite Index in 3,000 Knees | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Standardizing Joint-Line Determination on Anteroposterior Knee Radiographs: Multicenter Validation of the Adductor Ratio and a Novel Composite Index in 3,000 Knees Serhat Akcaalan, Ismail Duran, Mahmut Ugurlu, Salahulddin Abuljadail, and 18 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8278547/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Feb, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted 8 You are reading this latest preprint version Abstract Objective :To quantify how sex, age, and region affect radiographic joint-line (JL) measurements and indices on standardized AP knee radiographs across ten countries, and to identify a demography-resistant metric set for reliable JL restoration. Methods :Multicenter retrospective study of 3,000 AP knee radiographs (1,500 female/1,500 male; ages 20–79) from 10 countries . Standardized acquisition (SID 100 cm; AP, full extension, no rotation). Exclusions: prior peri-knee fracture/surgery, KL 3–4 OA, neurovascular deficit, septic arthritis, rheumatologic disease, BMI > 30, inadequate AP. Measurements: ATJL, FHJL, MEJL, LEJL, FW. Derived indices: literature-based ATJL/FW, FHJL/FW, MEJL/FW, LEJL/FW, JL1, JL2; newly defined JL-AF, JL-Combine, JL-Symmetry, JL-Ratio, JL3. Statistics: t-tests, one-/two-way ANOVA, multiple regression; effect sizes ( Cohen’s d, η²) ; variability ( CoV) . α=0.05. Results :Men showed higher FW (92.83 ± 11.15 vs 81.38 ± 8.54), ATJL (52.16 ± 6.31 vs 46.07 ± 5.46), FHJL (20.74 ± 4.05 vs 19.13 ± 4.04), MEJL (38.22 ± 8.96 vs 34.62 ± 7.67), and LEJL (35.35 ± 8.90 vs 32.07 ± 7.64); all p<0.001. With aging, FHJL, MEJL, and LEJL decreased (p 0.05). Region strongly impacted all variables (largest η²: LEJL 0.583, MEJL 0.561, FW 0.493) . Among derived metrics, ATJL/FW (η² = 0 .016, CoV = 0.228) and JL3 (η² = 0 .023, CoV = 0.235) were the most stable across demographics. JL-AF (η² = 0.036), JL-Combine (0.028), and JL-Symmetry (0.028) were low-dependency validators. FW-based JL1 (η² = 0.899) and JL2 (0.702) were demography-sensitive and unreliable as stand-alone predictors. Conclusion :Basic anatomic distances are demography-dependent and poor single guides for JL restoration. A normalize-and-combine strategy—using ATJL/FW as the anchor and JL3 as the composite confirmatory index (optionally cross-checked by JL-AF/JL-Combine/JL-Symmetry)—provides robust, transferable radiographic estimation across centers. Avoid single-variable FW models (e.g., JL1) in routine planning. Larger, population-level datasets should support personalized thresholds. joint line knee arthroplasty adductor tubercle normalized ratio composite index multicenter radiography Figures Figure 1 Introduction Restoring the joint line to its normal anatomical shape after both primary and revision knee arthroplasty has a significant effect on the knee joint[ 1 , 2 ]. A joint line (JL) that is more distal or proximal than normal can lead to worsening clinical and functional outcomes[ 3 ].This is because even a small change of 5 mm in the JL can cause instability, and clinical changes can occur with a JL change of more than 2 mm[ 3 – 6 ]. From a mechanical perspective, the displacement of the JL distally or proximally also has different effects on the knee joint.When the JL shifts proximally, patellofemoral compression forces increase, anterior knee pain occurs, polyethylene wear increases, joint range of motion becomes limited, and the risk of aseptic loosening increases[ 1 , 4 , 7 , 8 ].When the JL displaces distally, it can cause mid-flexion instability, restriction of knee joint range of motion, and again, an increased risk of aseptic loosening[ 9 ]. JL measurements can be performed using direct anterior-posterior (AP) knee radiographs. Different anatomical landmarks are used for these measurements. These are the fibular head[ 10 , 11 ], medial and lateral femoral epicondyles[ 12 ], and adductor tubercle[ 10 – 13 ].Unlike measurements taken directly from these landmarks, some authors have defined indices used to calculate JL, which they have shown to be more reliable, using these landmarks and femoral width[ 13 – 17 ]. Despite all these studies and different findings, there is still no JL measurement method whose validity is accepted by all sections. The authors designed this study because there is no universally accepted method in the literature and to investigate whether other accepted methods show differences based on gender, age, and region.The authors hypothesized that the parameters and existing indices used to determine JL in the literature would differ depending on age, gender, and region variables, and that a new index with limited influence from these variables should be defined. Materials and Methods Following the approval of the ethics committee of our hospital (xxx/xxxx), the data collection phase of the study was initiated. Digital archiving and communication systems of orthopedics and traumatology clinics in ten different countries (Turkey, Saudi Arabia, Italy, United Kingdom, Colombia, Argentina, Philippines, Mexico, India, Germany) were used to access the knee radiographs that were analyzed. All radiographs used for measurement were numbered instead of marked with the names of the patients to protect patient privacy. Measurements were performed on AP knee x-rays.Care was taken to ensure that all X-rays used for the study were taken using the same method. During X-ray imaging, the patient lay supine on the table with the knee and ankle joints in contact with the table, in full extension and without rotation of the knee, to achieve an .Centering for the image was performed at the center of the knee joint, 1.5 cm distal to the patella apex. The image was adjusted to fully include the femur superiorly, the proximal tibia and fibula inferiorly, and the medial-lateral skin borders bilaterally. In this process, the tube cassette distance was adjusted to 100 cm. The suitability of the obtained x-rays was evaluated by assessing whether the femoral and tibial condyles were symmetrical and whether the fibular head was slightly superimposed on the lateral tibial condyle.Those with a history of fracture around the knee or arthroscopic/open surgery, those with advanced arthritic findings in the knee (Kellgren–Lawrence stage 3–4), those with neurovascular deficits in the upper extremities, those with a history of septic arthritis, those diagnosed with rheumatological diseases, those with a body mass index > 30 kg/m², and those who could not have a full AP knee radiograph taken due to flexion contracture of the knee were excluded from the study. Patients were categorized according to gender, region, and age groups. In the study, 6 different age groups will be created as 20–29, 30–39, 40–49, 50–59, 60–69, and 70–79. There will be 25 female and 25 male patients in these age groups. These patients will have both right and left knees measured. All measurements were performed by two different orthopedists at the relevant clinics. The mean of the measurements taken was used for statistical analysis. All measurements described below were taken on knee AP x-rays and recorded separately for each patient (Fig. 1 ). Adductor tubercle to the joint line distance (ATJL) : Perpendicular distance between the adductor tubercle and joint line. The adductor tubercle was identified on the radiograph as the distal point on the medial supracondylar slope. Femoral width (FW) : Distance between the most external points of the medial and lateral epicondyles. Fibular head to joint line distance (FHJL) : Perpendicular distance between the most proximal point of the fibular head and the femoral joint line Distance from medial epicondyle to medial most distal point (MEJL) : Perpendicular distance between the medial epicondyle and the joint line Distance from lateral epicondyle to lateral most distal point (LEJL) : Perpendicular distance between the lateral epicondyle and the femoral joint line Using the measurements specified above, the indices defined in the literature for determining the JL, along with their references listed below, were calculated in the second stage and recorded separately for all patients. • ATJL/FW[ 18 ] • FHJL/FW[ 19 ] • MEJL/FW[ 19 ] LEJL/FW[ 19 ] All data were recorded in an electronic data program (Microsoft Excel) for statistical analysis. Statistical Analysis: Data analysis was performed using the SPSS 27.0 program and conducted at a 95% confidence level. For categorical (qualitative) variables, frequency (n) and percentage (%) were provided, while for numerical (quantitative) variables, mean (Mean), standard deviation (SD), minimum, and maximum statistics were provided. Independent groups t-tests, one-way ANOVA, two-way ANOVA, and multiple linear regression analyses were used in the study. In addition, LSD (for homogeneous variance) and Tamhane (for non-homogeneous variance) tests were used for within-group comparisons, and effect size (Cohen's d and Eta2) was calculated to examine group effects. Independent groups t; a test technique used to compare two groups in terms of a numerical variable. One-way ANOVA; a test technique used to compare two groups in terms of a numerical variable. Two-way ANOVA; a test technique used to determine the effects on a numerical variable in an ANOVA model of an experimental design involving two or more groups of variables. Multiple linear regression is a type of analysis that examines the effect of more than one independent variable on a numerical dependent variable. Results A total of 3000 patients, including 1500 (50%) men and 1500 (50%) women, were included in the study. 300 knee AP x-rays were included, 150 from women and 150 from men from each country. FW was found to be 81.38 ± 8.54 in women and 92.83 ± 11.15 in men. FW was found to be statistically higher in men (p = 0.000). ATJL was found to be 46.07 ± 5.46 in women and 52.16 ± 6.31 in men.Statistically, a higher mean value was found in men (p = 0.000). FHJL was 19.13 ± 4.04 in women and 20.74 ± 4.052 in men.FHJL values in men were found to be statistically significantly higher (p = 0.000). MEJL was 34.62 ± 7.67 in women and 38.22 ± 8.96 in men.A statistically significant increase was found in men (p = 0.000). LEJL was 32.07 ± 7.64 in women and 38.22 ± 8.96 in men. A statistically significant increase was found in men (p = 0.000). The data from the analysis of the measurements according to age groups are shared in Table 1 . Table 1 Analysis of measurements according to age groups in the study. Variables Age n Mean sd F p Eta2 Post Hoc FW 20–29(1) 500 85.67 10.57 2,084 0.064 0.003 x 30–39(2) 500 87.10 11.07 40–49(3) 500 87.19 11.68 50–59(4) 500 87.70 12.11 60–69(5) 500 87.40 11.29 70–79(6) 500 87.58 11.93 ATJL 20–29(1) 500 48.47 6.41 1,403 0.220 0.002 x 30–39(2) 500 49.02 6.72 40–49(3) 500 49.15 6.23 50–59(4) 500 49.21 6.68 60–69(5) 500 49.40 6.85 70–79(6) 500 49.43 6.90 FHJL 20–29(1) 500 20.40 4.03 6,208 0.000 0.010 1–3 1-4 1-5 1-6 2-3 2-4 2-5 2–6 30–39(2) 500 20.57 3.97 40–49(3) 500 19.38 4.06 50–59(4) 500 19.84 4.20 60–69(5) 500 19.79 4.25 70–79(6) 500 19.62 4.14 MEJL 20–29(1) 500 37.76 7.54 15,205 0.000 0.025 1–3 1-4 1-5 1-6 2-3 2-4 2-5 2–6 30–39(2) 500 38.62 7.75 40–49(3) 500 36.22 8.48 50–59(4) 500 35.38 8.68 60–69(5) 500 35.78 9.05 70–79(6) 500 34.78 8.98 LEJL 20–29(1) 500 34.55 7.31 12,092 0.000 0.020 6 − 1 6-2 6-3 2-4 2-5 30–39(2) 500 35.54 7.66 40–49(3) 500 34.14 8.49 50–59(4) 500 33.10 8.78 60–69(5) 500 33.07 9.14 70–79(6) 500 31.85 8.75 Data from the analysis of measurements by country is shared in Table 2 . Table 2 Analysis of measurements by country in the study. Variables Region n Mean sd F p Eta2 Post Hoc FW Argentina 300 87.20 9.10 193,443 0.000 0.368 ** Colombia 300 88.48 8.70 Germany 300 91.96 9.28 India 300 66.79 5.27 Italy 300 89.71 12.52 Mexico 300 91.00 8.84 Philippines 300 88.04 9.67 Saudi Arabia 300 90.09 8.78 Turkey 300 86.98 7.69 UK 300 90.81 9.80 ATJL Argentina 300 48.94 5.22 168,731 0.000 0.337 ** Colombia 300 47.66 5.48 Germany 300 52.03 5.33 India 300 38.37 4.24 Italy 300 51.67 6.21 Mexico 300 52.08 5.81 Philippines 300 49.51 5.61 Saudi Arabia 300 51.42 5.44 Turkey 300 49.09 4.74 UK 300 50.37 5.80 FHJL Argentina 300 18.62 4.14 7,879 0.000 0.023 ** Colombia 300 19.76 4.46 Germany 300 20.90 4.57 India 300 20.31 3.04 Italy 300 20.48 3.97 Mexico 300 19.91 4.32 Philippines 300 19.82 3.85 Saudi Arabia 300 20.47 4.43 Turkey 300 19.24 3.55 UK 300 19.82 4.29 MEJL Argentina 300 40.54 4.33 363,384 0.000 0.522 ** Colombia 300 34.95 4.13 Germany 300 37.66 4.57 India 300 23.80 2.85 Italy 300 36.20 8.21 Mexico 300 33.74 3.47 Philippines 300 40.50 6.94 Saudi Arabia 300 46.50 4.67 Turkey 300 29.20 10.77 UK 300 41.16 4.29 LEJL Argentina 300 37.42 4.72 465,038 0.000 0.583 ** Colombia 300 32.32 3.66 Germany 300 33.80 3.67 India 300 19.20 1.81 Italy 300 35.46 8.49 Mexico 300 31.60 3.33 Philippines 300 38.04 6.50 Saudi Arabia 300 41.97 4.48 Turkey 300 26.70 9.16 UK 300 40.58 4.11 Following the analysis of basic measurements and indices previously used in the literature to determine JL according to gender, age, and region variables, new indices were created. These are: JL AF : (ATJL + FHJL) / (2*FW) JL Combine : (ATJL + FHJL + MEJL + LEJL) / (4*FW) JL Symmetry : (MEJL – LEJL) / FW JL Ratio : (ATJL/FW) / (FHJL/FW) JL 1 : 0.27 * FW + 13.5 JL 2 : 0.3 * ATJL + 0.4 * FHJL + 0.3 * MEJL JL 3 : 1.004 × ATJL + 0.093 × FHJL – 0.070 × MEJL + 0.391 × LEJL In the variance analysis conducted by gender, statistically significant differences were found in FW, ATJL, FHJL, MEJL, LEJL, FHJL/FW, MEJL/FW, and LEJL/FW, as well as in JL AF, JL 1, and JL Index 2 (p 0.05). When examining effect sizes, the highest Cohen's d values were observed in MEJL (d = 0.057) and LEJL (d = 0.052) measurements, followed by JL 2 (d = 0.023). Effect sizes remained low in all other measurements (d < 0.02).In the analyses conducted in terms of age, statistically significant differences were found in FW, ATJL, FHJL, MEJL, LEJL, FHJL/FW, MEJL/FW, and LEJL/FW, as well as JL AF, JL 1, and JL 2 (p 0.05). When examining effect sizes, the highest η² values were observed in FW (η² = 0.397), ATJL (η² = 0.319), and JL 2 (η² = 0.240).Significant but lower-level effects ( ) were also detected in MEJL (η² = 0.098) and LEJL (η² = 0.095) measurements. In normalized indices, effect sizes remained quite low (η² < 0.01).In the analyses based on the country factor, statistically significant differences were found in all raw measurements (FW, ATJL, FHJL, MEJL, LEJL), normalized measurements (ATJL/FW, FHJL/FW, MEJL/FW, LEJL/FW), and all indices (JL AF, JL Combine, JL Symetri, JL Ratio, JL 1, JL 2, JL 3) were statistically significant (p < 0.05). When examining effect sizes, the highest η² values were observed in LEJL (η² = 0.619), MEJL (η² = 0.561), FW (η² = 0.493), and JL Index 1 (η² = 0.493). Furthermore, ATJL (η² = 0.428) and JL 2 (η² = 0.439) were also among the measurements strongly affected by the country factor. Among the normalized measurements, the most significant differences were found in the LEJL/FW (η² = 0.206), MEJL/FW (η² = 0.175), and FHJL/FW (η² = 0.125) ratios. A comparison of the measurements made in the study with previously established and newly created indices is provided in Table 3 . Table 3 Joint line measurements and derived indices in AP knee radiographs: Mean (SD), effect size (η²), coefficient of variation (CoV), and stability score Variables Mean sd Eta2 CoV Stability Score FW 87.11 11.46 0.899 0.132 1.000 ATJL 49.11 6.64 0.752 0.135 0.887 FHJL 19.93 4.13 0.074 0.207 0.281 MEJL 36.42 8.53 0.716 0.234 0.950 LEJL 33.71 8.46 0.766 0.251 1,000 ATJL/FW 0.57 0.13 0.016 0.228 0.244 FHJL/FW 0.23 0.07 0.136 0.305 0.441 MEJL/FW 0.42 0.13 0.195 0.309 0.504 LEJL/FW 0.39 0.13 0.223 0.333 0.556 JL AF 0.40 0.09 0.036 0.230 0.266 JL Combine 0.40 0.09 0.028 0.233 0.261 JL Symmetry 0.77 0.19 0.028 0.241 0.269 JL Ratio 0.40 0.10 0.074 0.254 0.328 JL 1 0.37 0.03 0.899 0.084 0.983 JL 2 0.34 0.05 0.702 0.137 0.839 JL 3 0.71 0.17 0.023 0.235 0.258 Figure Legends : According to the data in Table 3 , FW and basic measurements (ATJL, MEJL, LEJL) are highly influenced by demographic factors and are limited in terms of stability.Normalized ratios (especially ATJL/FW) and combined indices (JL AF, JL Combine, JL Symmetry, JL 3) emerged as the most reliable measures with low StabilityScore values.Specifically, JL 3 and JL AF/Combined indices have been identified as the most stable indicators, independent of demographic factors and with a low coefficient of variation. Discussion The most important finding of this study is that Basic anatomical measurements used to determine JL, such as FW, ATJL, FHJL, MEJL, and LEJL, are greatly affected by demographic variables and cannot be used alone to determine JL. The most reliable parameters for determining JL, which are least affected by demographic data, are ATJL/FW and JL 3.Furthermore, this study demonstrated that different indices previously defined in the literature as normalized ratios and considered reliable may vary depending on demographic data and therefore cannot be used reliably. Iacano and colleagues, in their study to identify methods that could be used to determine JL, compared radiographic measurements with intraoperative measurements[ 13 ]. As a result, they found that the ATJL/FW ratio showed the highest agreement between radiographic measurement and intraoperative measurement.In their study evaluating full-leg standing x-rays of 100 healthy volunteers, Luyckx and colleagues demonstrated, similarly to the previous study, that the ATJL/FW ratio could be reliable and accurate for JL reconstruction, particularly in revision total knee arthroplasty[ 20 ].Akça and colleagues also used both traditional and ratio-based methods to determine the JL in revision total knee arthroplasty ( ) in their study, where they compared their radiographic measurements with intraoperative measurements.In this study, which used data from 16 revision knee arthroplasty patients, the Adductor Tubercle-Ratios method was shown to be a more reliable and usable method for determining the JL[ 21 ]. Yüksel and colleagues, in a retrospective study involving 186 patients[ 22 ] stated that the AT is a reliable landmark for determining the JL[In another study, anatomical landmarks that could be used to determine the JL were evaluated comparatively. This study also stated that the AT is a suitable anatomical landmark for determining the JL in revision surgeries[[ 23 ]In another study, Iacona demonstrated that the ATJL/FW ratio can be appropriately used to determine the JL in revision knee surgeries using an intraoperative control method[ 24 ]. Unlike these radiographic and intraoperative measurements, Maderbacher and colleagues conducted an MRI-based study to determine the JL.In this study, different measurements of FH, AT, ME, and LE were used; as a result, they showed that a healthy JL restoration cannot be achieved with direct bone-based measurements and that an index such as "6.40 + (width femur [mm] × 0.49) to the AT" can be used[ 25 ].In their study on JL determination in the Chinese population, Gao and colleagues stated that different formulations should be created for women and men for reliable JL detection and concluded that the formulation "ATJL = 0.562 × FW" could be used for women and "ATJL = 0.548 × FW" for men[ 26 ]. In their study using 50 X-rays taken with a standardized protocol, Xia and colleagues emphasized that AT is a reliable landmark and demonstrated that combinations with FW can be used[ 27 ].Fan and colleagues, in their study on the Chinese population, emphasized that ME and LE are also usable landmarks besides AT, but warned that ratios need to be established according to different races [ 28 ]. There are numerous studies in the literature related to determining JL, which include different results, but most of them have not revealed the effect of demographic variables such as age, gender, and region.In contrast, our study has detailed the effects of these variables and determined how JL can be identified using parameters that are least affected by these variables. Although our study draws conclusions based on a broader analysis than other studies, it is not possible to know the natural JL of every individual.Therefore, as stated by Hirschmann et al[ 29 ], larger databases should be created and a transition to personalized medicine should be made, using individualized values for coronal plane deformity analysis and preoperative planning. This study is methodologically robust due to its multicenter, large, and balanced sample (n = 3000; 10 countries), standard AP imaging following a single protocol (SID = 100 cm, full extension, no rotation), strict exclusion criteria, and use of the average measurements of two observers; beyond the p-value, it systematically maps effect size (η², d) and CoV with demographic sensitivity, defines JL3 and other composite/normalized indices in addition to literature ratios, and provides an applicable framework for a demographic-resistant decision metric. However, the design is retrospective-cross-sectional, lacks external validation with intraoperative/clinical outcomes, does not assess observer reliability (ICC); despite symmetry filters, there is a risk of rotation/collimation artifacts and magnification differences between devices despite SID standardization; KL 3–4 and BMI > 30 exclusions limit generalizability. Conclusion Consequently, basic measurements such as ATJL, FHJL, MEJL, LEJL, and FW, which are performed using direct landmarks, should not be used for JL detection because they show significant variations depending on demographic parameters. The ATJL/FW and JL 1 indices, which are the parameters least affected by demographic data, can be used reliably together or separately for JL detection.However, both primary and revision surgeries require broader and more personalized data for the anatomical restoration of JL. Declarations Acknowledgements : None Funding: No funding was received for this study. Conflict of Interest: The authors declare that there is no conflict of interest. Ethical Approval: Ethical approval has been obtained and will be uploaded as an additional file. Informed Consent: This study is a retrospective screening study; informed consent was not applicable. Authors’ Contribution: SA, ID, MU, SAJ, LA, AR, MF, MZ, AY, FF, EP, MBLV, ALB, JGP, DRR, DS, JI, KH, NG, GA, MFD, and MC contributed to study design and data collection. SA and ID developed the theoretical framework, performed analytic calculations, and contributed to data interpretation. MU contributed to data analysis and manuscript preparation. MC supervised the overall project. All authors reviewed and approved the final version of the manuscript. References Akça MÇ, Akalın Y, Çevik N, Şahin İG, Avcı Ö, Öztürk A (2020) Joint line reestablishment in revision total knee arthroplasty. 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J Arthroplasty 10(6):785–789 Weber P, Schröder C, Laubender RP, Baur-Melnyk A, von Schulze Pellengahr C, Jansson V, Müller PE (2013) Joint line reconstruction in medial unicompartmental knee arthroplasty: development and validation of a measurement method. Knee Surg Sports Traumatol Arthrosc 21(11):2468–2473 Wyss TF, Schuster AJ, Münger P, Pfluger D, Wehrli U (2006) Does total knee joint replacement with the soft tissue balancing surgical technique maintain the natural joint line? Arch Orthop Trauma Surg 126(7):480–486 Xiao J, Wang S, Chen W, Yang Y, Liu T, Zuo J (2017) A Study to Assess the Accuracy of Adductor Tubercle as a Reliable Landmark Used to Determine the Joint Line of the Knee in a Chinese Population. J Arthroplasty 32(4):1351–1355 Yeh KT, Chen IH, Wang CC, Wu WT, Liu KL, Peng CH (2019) The adductor tubercle can be a radiographic landmark for joint line position determination: an anatomic-radiographic correlation study. J Orthop Surg ResDOI. 10.1186/S13018-019-1221-Y Yoshii I, Whiteside LA, White SE, Milliano MT (1991) Influence of prosthetic joint line position on knee kinematics and patellar position. J Arthroplasty 6(2):169–177 Yüksel Y, Akar MS (2025) Adductor tubercle as a reliable landmark for knee joint line determination: a comparative radiological study. Arch Orthop Trauma SurgDOI. 10.1007/S00402-025-06031-3 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Feb, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted Editorial decision: Revision requested 18 Dec, 2025 Reviews received at journal 17 Dec, 2025 Reviewers agreed at journal 11 Dec, 2025 Reviewers agreed at journal 09 Dec, 2025 Reviewers invited by journal 09 Dec, 2025 Editor assigned by journal 06 Dec, 2025 Submission checks completed at journal 06 Dec, 2025 First submitted to journal 04 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8278547","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":558860825,"identity":"d57462c1-0e09-47e2-a573-e2222e88222e","order_by":0,"name":"Serhat Akcaalan","email":"","orcid":"","institution":"Ankara City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Serhat","middleName":"","lastName":"Akcaalan","suffix":""},{"id":558860826,"identity":"febc1d48-5a54-487d-ac6e-db6af4a7468f","order_by":1,"name":"Ismail Duran","email":"","orcid":"","institution":"Dr Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Ismail","middleName":"","lastName":"Duran","suffix":""},{"id":558860827,"identity":"64113715-1eb0-4f39-afe5-b2828f1e7bbe","order_by":2,"name":"Mahmut Ugurlu","email":"","orcid":"","institution":"Ankara City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mahmut","middleName":"","lastName":"Ugurlu","suffix":""},{"id":558860828,"identity":"2ad9961d-5dd4-4c17-b534-e26f14befd13","order_by":3,"name":"Salahulddin Abuljadail","email":"","orcid":"","institution":"King Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Salahulddin","middleName":"","lastName":"Abuljadail","suffix":""},{"id":558860829,"identity":"a423eb6c-676a-4aff-ad20-d7170aef0bb8","order_by":4,"name":"Lina Almudayres","email":"","orcid":"","institution":"King Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Lina","middleName":"","lastName":"Almudayres","suffix":""},{"id":558860830,"identity":"ccf84261-5c47-4090-8894-1ab6947b6652","order_by":5,"name":"Antonio Russo","email":"","orcid":"","institution":"Humanitas Torino","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Russo","suffix":""},{"id":558860832,"identity":"ebab695e-a045-4619-a83c-259ff88ba5ad","order_by":6,"name":"Mattia Forgini","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Mattia","middleName":"","lastName":"Forgini","suffix":""},{"id":558860833,"identity":"d32588ad-e8ab-4864-89e9-2afa1de095c9","order_by":7,"name":"Moez Zeiton","email":"","orcid":"","institution":"Royal Bolton Hospital","correspondingAuthor":false,"prefix":"","firstName":"Moez","middleName":"","lastName":"Zeiton","suffix":""},{"id":558860834,"identity":"e4fd2319-7188-40bf-afbc-756ee87b5045","order_by":8,"name":"Alexander Yan","email":"","orcid":"","institution":"Health Education North West","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Yan","suffix":""},{"id":558860835,"identity":"beee5caf-e720-42a3-a78a-fd8fcfa003cf","order_by":9,"name":"Felipo Forero","email":"","orcid":"","institution":"Los Comuneros Hospital Universitario de Bucaramanga","correspondingAuthor":false,"prefix":"","firstName":"Felipo","middleName":"","lastName":"Forero","suffix":""},{"id":558860836,"identity":"31ab3128-a6d7-42d9-8e00-d69f54ea3159","order_by":10,"name":"Elliot Patarroyo","email":"","orcid":"","institution":"Los Comuneros Hospital Universitario de Bucaramanga","correspondingAuthor":false,"prefix":"","firstName":"Elliot","middleName":"","lastName":"Patarroyo","suffix":""},{"id":558860837,"identity":"2908c8b5-1b54-427c-86b4-c6dc03695d88","order_by":11,"name":"María Belén López Villagra","email":"","orcid":"","institution":"Sanatorio Allende","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"Belén López","lastName":"Villagra","suffix":""},{"id":558860838,"identity":"d627bf02-cda4-43fb-b591-2163dfe8e1f8","order_by":12,"name":"Ana Laura Bogado","email":"","orcid":"","institution":"Sanatorio Allende","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Laura","lastName":"Bogado","suffix":""},{"id":558860839,"identity":"7e99a92c-2dda-4e9a-8fee-3b69a06552d4","order_by":13,"name":"Julius G. 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16:18:48","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":120600,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8278547/v1/a1c388234a46f0f067bb414a.html"},{"id":98246252,"identity":"b8a81065-af82-4950-9432-c5cfc1721312","added_by":"auto","created_at":"2025-12-15 16:18:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":622395,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSchematic illustration of the radiographic and anatomical landmarks used for joint-line assessment.\u003c/em\u003e\u003cbr\u003e\n(Left) Standardized anteroposterior knee view showing femoral width (FW), adductor tubercle–joint line distance (ATJL), and reference joint-line (JL). The adductor tubercle (AT) is used as the proximal landmark for ATJL measurement.\u003cbr\u003e\n(Right) Anatomical points relevant for mediolateral joint-line evaluation, including the medial proximal lateral condylar point (MPLC), medial proximal medial condylar point (MPMC), lateral condylar distal point (LCDP), and medial condylar distal point (MCDP). These landmarks form the basis for derived indices and composite measurements used in joint-line restoration analysis.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8278547/v1/5e77f21845f239b73db78214.jpg"},{"id":102234279,"identity":"b6977547-ff00-4735-a8b3-e2429f28f12f","added_by":"auto","created_at":"2026-02-09 16:09:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1854778,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8278547/v1/6b45336d-db27-4b2d-bbe7-e7149c98c83f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Standardizing Joint-Line Determination on Anteroposterior Knee Radiographs: Multicenter Validation of the Adductor Ratio and a Novel Composite Index in 3,000 Knees","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRestoring the joint line to its normal anatomical shape after both primary and revision knee arthroplasty has a significant effect on the knee joint[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A joint line (JL) that is more distal or proximal than normal can lead to worsening clinical and functional outcomes[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].This is because even a small change of 5 mm in the JL can cause instability, and clinical changes can occur with a JL change of more than 2 mm[\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. From a mechanical perspective, the displacement of the JL distally or proximally also has different effects on the knee joint.When the JL shifts proximally, patellofemoral compression forces increase, anterior knee pain occurs, polyethylene wear increases, joint range of motion becomes limited, and the risk of aseptic loosening increases[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].When the JL displaces distally, it can cause mid-flexion instability, restriction of knee joint range of motion, and again, an increased risk of aseptic loosening[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eJL measurements can be performed using direct anterior-posterior (AP) knee radiographs. Different anatomical landmarks are used for these measurements. These are the fibular head[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], medial and lateral femoral epicondyles[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and adductor tubercle[\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].Unlike measurements taken directly from these landmarks, some authors have defined indices used to calculate JL, which they have shown to be more reliable, using these landmarks and femoral width[\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Despite all these studies and different findings, there is still no JL measurement method whose validity is accepted by all sections.\u003c/p\u003e\u003cp\u003eThe authors designed this study because there is no universally accepted method in the literature and to investigate whether other accepted methods show differences based on gender, age, and region.The authors hypothesized that the parameters and existing indices used to determine JL in the literature would differ depending on age, gender, and region variables, and that a new index with limited influence from these variables should be defined.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e Following the approval of the ethics committee of our hospital (xxx/xxxx), the data collection phase of the study was initiated. Digital archiving and communication systems of orthopedics and traumatology clinics in ten different countries (Turkey, Saudi Arabia, Italy, United Kingdom, Colombia, Argentina, Philippines, Mexico, India, Germany) were used to access the knee radiographs that were analyzed. All radiographs used for measurement were numbered instead of marked with the names of the patients to protect patient privacy. Measurements were performed on AP knee x-rays.Care was taken to ensure that all X-rays used for the study were taken using the same method. During X-ray imaging, the patient lay supine on the table with the knee and ankle joints in contact with the table, in full extension and without rotation of the knee, to achieve an .Centering for the image was performed at the center of the knee joint, 1.5 cm distal to the patella apex. The image was adjusted to fully include the femur superiorly, the proximal tibia and fibula inferiorly, and the medial-lateral skin borders bilaterally. In this process, the tube cassette distance was adjusted to 100 cm. The suitability of the obtained x-rays was evaluated by assessing whether the femoral and tibial condyles were symmetrical and whether the fibular head was slightly superimposed on the lateral tibial condyle.Those with a history of fracture around the knee or arthroscopic/open surgery, those with advanced arthritic findings in the knee (Kellgren\u0026ndash;Lawrence stage 3\u0026ndash;4), those with neurovascular deficits in the upper extremities, those with a history of septic arthritis, those diagnosed with rheumatological diseases, those with a body mass index\u0026thinsp;\u0026gt;\u0026thinsp;30 kg/m\u0026sup2;, and those who could not have a full AP knee radiograph taken due to flexion contracture of the knee were excluded from the study.\u003c/p\u003e\u003cp\u003ePatients were categorized according to gender, region, and age groups. In the study, 6 different age groups will be created as 20\u0026ndash;29, 30\u0026ndash;39, 40\u0026ndash;49, 50\u0026ndash;59, 60\u0026ndash;69, and 70\u0026ndash;79. There will be 25 female and 25 male patients in these age groups. These patients will have both right and left knees measured. All measurements were performed by two different orthopedists at the relevant clinics. The mean of the measurements taken was used for statistical analysis.\u003c/p\u003e\u003cp\u003eAll measurements described below were taken on knee AP x-rays and recorded separately for each patient (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eAdductor tubercle to the joint line distance (ATJL)\u003c/b\u003e: Perpendicular distance between the adductor tubercle and joint line. The adductor tubercle was identified on the radiograph as the distal point on the medial supracondylar slope.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eFemoral width (FW)\u003c/b\u003e: Distance between the most external points of the medial and lateral epicondyles.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eFibular head to joint line distance (FHJL)\u003c/b\u003e: Perpendicular distance between the most proximal point of the fibular head and the femoral joint line\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDistance from medial epicondyle to medial most distal point (MEJL)\u003c/b\u003e: Perpendicular distance between the medial epicondyle and the joint line\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDistance from lateral epicondyle to lateral most distal point (LEJL)\u003c/b\u003e: Perpendicular distance between the lateral epicondyle and the femoral joint line\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eUsing the measurements specified above, the indices defined in the literature for determining the JL, along with their references listed below, were calculated in the second stage and recorded separately for all patients.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e\u0026bull; ATJL/FW[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/h2\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003e\u0026bull; FHJL/FW[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/h2\u003e\u003cdiv id=\"Sec5\" class=\"Section4\"\u003e\u003ch2\u003e\u0026bull; MEJL/FW[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eLEJL/FW[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eAll data were recorded in an electronic data program (Microsoft Excel) for statistical analysis.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis:\u003c/h2\u003e\u003cp\u003eData analysis was performed using the SPSS 27.0 program and conducted at a 95% confidence level. For categorical (qualitative) variables, frequency (n) and percentage (%) were provided, while for numerical (quantitative) variables, mean (Mean), standard deviation (SD), minimum, and maximum statistics were provided. Independent groups t-tests, one-way ANOVA, two-way ANOVA, and multiple linear regression analyses were used in the study. In addition, LSD (for homogeneous variance) and Tamhane (for non-homogeneous variance) tests were used for within-group comparisons, and effect size (Cohen's d and Eta2) was calculated to examine group effects. Independent groups t; a test technique used to compare two groups in terms of a numerical variable. One-way ANOVA; a test technique used to compare two groups in terms of a numerical variable. Two-way ANOVA; a test technique used to determine the effects on a numerical variable in an ANOVA model of an experimental design involving two or more groups of variables. Multiple linear regression is a type of analysis that examines the effect of more than one independent variable on a numerical dependent variable.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 3000 patients, including 1500 (50%) men and 1500 (50%) women, were included in the study. 300 knee AP x-rays were included, 150 from women and 150 from men from each country.\u003c/p\u003e\u003cp\u003eFW was found to be 81.38\u0026thinsp;\u0026plusmn;\u0026thinsp;8.54 in women and 92.83\u0026thinsp;\u0026plusmn;\u0026thinsp;11.15 in men. FW was found to be statistically higher in men (p\u0026thinsp;=\u0026thinsp;0.000). ATJL was found to be 46.07\u0026thinsp;\u0026plusmn;\u0026thinsp;5.46 in women and 52.16\u0026thinsp;\u0026plusmn;\u0026thinsp;6.31 in men.Statistically, a higher mean value was found in men (p\u0026thinsp;=\u0026thinsp;0.000). FHJL was 19.13\u0026thinsp;\u0026plusmn;\u0026thinsp;4.04 in women and 20.74\u0026thinsp;\u0026plusmn;\u0026thinsp;4.052 in men.FHJL values in men were found to be statistically significantly higher (p\u0026thinsp;=\u0026thinsp;0.000). MEJL was 34.62\u0026thinsp;\u0026plusmn;\u0026thinsp;7.67 in women and 38.22\u0026thinsp;\u0026plusmn;\u0026thinsp;8.96 in men.A statistically significant increase was found in men (p\u0026thinsp;=\u0026thinsp;0.000). LEJL was 32.07\u0026thinsp;\u0026plusmn;\u0026thinsp;7.64 in women and 38.22\u0026thinsp;\u0026plusmn;\u0026thinsp;8.96 in men. A statistically significant increase was found in men (p\u0026thinsp;=\u0026thinsp;0.000).\u003c/p\u003e\u003cp\u003eThe data from the analysis of the measurements according to age groups are shared in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAnalysis of measurements according to age groups in the study.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth 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colname=\"c2\"\u003e\u003cp\u003e30\u0026ndash;39(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e49.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u0026ndash;49(3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e49.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u0026ndash;59(4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" 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colname=\"c4\"\u003e\u003cp\u003e49.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.90\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eFHJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u0026ndash;29(1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e6,208\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e1\u0026ndash;3 1-4\u003c/p\u003e\u003cp\u003e1-5 1-6\u003c/p\u003e\u003cp\u003e2-3 2-4\u003c/p\u003e\u003cp\u003e2-5 2\u0026ndash;6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u0026ndash;39(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.97\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u0026ndash;49(3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u0026ndash;59(4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60\u0026ndash;69(5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70\u0026ndash;79(6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eMEJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u0026ndash;29(1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e37.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e15,205\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e1\u0026ndash;3 1-4\u003c/p\u003e\u003cp\u003e1-5 1-6\u003c/p\u003e\u003cp\u003e2-3 2-4\u003c/p\u003e\u003cp\u003e2-5 2\u0026ndash;6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u0026ndash;39(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u0026ndash;49(3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e36.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u0026ndash;59(4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60\u0026ndash;69(5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70\u0026ndash;79(6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.98\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eLEJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u0026ndash;29(1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e12,092\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e0.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e6\u0026thinsp;\u0026minus;\u0026thinsp;1 6-2\u003c/p\u003e\u003cp\u003e6-3 2-4\u003c/p\u003e\u003cp\u003e2-5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u0026ndash;39(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.66\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u0026ndash;49(3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u0026ndash;59(4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60\u0026ndash;69(5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70\u0026ndash;79(6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData from the analysis of measurements by country is shared in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAnalysis of measurements by country in the study.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003esd\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eEta2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ePost Hoc\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003eFW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eArgentina\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e87.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e193,443\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e0.368\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eColombia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e88.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGermany\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e91.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e66.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e89.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12.52\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMexico\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e91.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhilippines\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e88.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSaudi Arabia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e90.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTurkey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e86.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUK\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e90.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003eATJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eArgentina\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e48.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e168,731\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e0.337\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eColombia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e47.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGermany\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e52.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMexico\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e52.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhilippines\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e49.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.61\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSaudi Arabia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTurkey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e49.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.74\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUK\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003eFHJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eArgentina\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e7,879\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eColombia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGermany\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.97\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMexico\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhilippines\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSaudi Arabia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.43\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTurkey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUK\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003eMEJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eArgentina\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e363,384\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e0.522\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eColombia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGermany\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e37.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e36.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMexico\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhilippines\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.94\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSaudi Arabia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e46.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTurkey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e29.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10.77\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUK\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e41.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003eLEJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eArgentina\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e37.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e465,038\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e0.583\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eColombia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e32.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.66\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGermany\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMexico\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhilippines\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSaudi Arabia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e41.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTurkey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUK\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFollowing the analysis of basic measurements and indices previously used in the literature to determine JL according to gender, age, and region variables, new indices were created. These are:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eJL AF\u003c/b\u003e: (ATJL\u0026thinsp;+\u0026thinsp;FHJL) / (2*FW)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eJL Combine\u003c/b\u003e: (ATJL\u0026thinsp;+\u0026thinsp;FHJL\u0026thinsp;+\u0026thinsp;MEJL\u0026thinsp;+\u0026thinsp;LEJL) / (4*FW)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eJL Symmetry\u003c/b\u003e: (MEJL \u0026ndash; LEJL) / FW\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eJL Ratio\u003c/b\u003e: (ATJL/FW) / (FHJL/FW)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eJL 1\u003c/b\u003e: 0.27 * FW\u0026thinsp;+\u0026thinsp;13.5\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eJL 2\u003c/b\u003e: 0.3 * ATJL\u0026thinsp;+\u0026thinsp;0.4 * FHJL\u0026thinsp;+\u0026thinsp;0.3 * MEJL\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eJL 3\u003c/b\u003e: 1.004 \u0026times; ATJL\u0026thinsp;+\u0026thinsp;0.093 \u0026times; FHJL \u0026ndash; 0.070 \u0026times; MEJL\u0026thinsp;+\u0026thinsp;0.391 \u0026times; LEJL\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eIn the variance analysis conducted by gender, statistically significant differences were found in FW, ATJL, FHJL, MEJL, LEJL, FHJL/FW, MEJL/FW, and LEJL/FW, as well as in JL AF, JL 1, and JL Index 2 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In contrast, the effect of gender was not statistically significant in ATJL/FW, JL Average Index, JL Combine, JL Symmetry, and JL 3 (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). When examining effect sizes, the highest Cohen's d values were observed in MEJL (d\u0026thinsp;=\u0026thinsp;0.057) and LEJL (d\u0026thinsp;=\u0026thinsp;0.052) measurements, followed by JL 2 (d\u0026thinsp;=\u0026thinsp;0.023). Effect sizes remained low in all other measurements (d\u0026thinsp;\u0026lt;\u0026thinsp;0.02).In the analyses conducted in terms of age, statistically significant differences were found in FW, ATJL, FHJL, MEJL, LEJL, FHJL/FW, MEJL/FW, and LEJL/FW, as well as JL AF, JL 1, and JL 2 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In contrast, no age-related significant difference was found for ATJL/FW, JL Ratio, JL Combine, JL Symmetry, and JL 3 (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). When examining effect sizes, the highest η\u0026sup2; values were observed in FW (η\u0026sup2; = 0.397), ATJL (η\u0026sup2; = 0.319), and JL 2 (η\u0026sup2; = 0.240).Significant but lower-level effects ( ) were also detected in MEJL (η\u0026sup2; = 0.098) and LEJL (η\u0026sup2; = 0.095) measurements. In normalized indices, effect sizes remained quite low (η\u0026sup2; \u0026lt; 0.01).In the analyses based on the country factor, statistically significant differences were found in all raw measurements (FW, ATJL, FHJL, MEJL, LEJL), normalized measurements (ATJL/FW, FHJL/FW, MEJL/FW, LEJL/FW), and all indices (JL AF, JL Combine, JL Symetri, JL Ratio, JL 1, JL 2, JL 3) were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). When examining effect sizes, the highest η\u0026sup2; values were observed in LEJL (η\u0026sup2; = 0.619), MEJL (η\u0026sup2; = 0.561), FW (η\u0026sup2; = 0.493), and JL Index 1 (η\u0026sup2; = 0.493). Furthermore, ATJL (η\u0026sup2; = 0.428) and JL 2 (η\u0026sup2; = 0.439) were also among the measurements strongly affected by the country factor. Among the normalized measurements, the most significant differences were found in the LEJL/FW (η\u0026sup2; = 0.206), MEJL/FW (η\u0026sup2; = 0.175), and FHJL/FW (η\u0026sup2; = 0.125) ratios.\u003c/p\u003e\u003cp\u003eA comparison of the measurements made in the study with previously established and newly created indices is provided in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eJoint line measurements and derived indices in AP knee radiographs: Mean (SD), effect size (η\u0026sup2;), coefficient of variation (CoV), and stability score\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003esd\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEta2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCoV\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eStability Score\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e87.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.899\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eATJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e49.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.752\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.135\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.887\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFHJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.074\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.207\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.281\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMEJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e36.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.716\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.234\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.950\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLEJL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.766\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.251\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1,000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eATJL/FW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.228\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.244\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFHJL/FW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.136\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.305\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.441\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMEJL/FW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.195\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.309\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.504\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLEJL/FW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.223\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.556\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJL AF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.230\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.266\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJL Combine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.233\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.261\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJL Symmetry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.241\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.269\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJL Ratio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.074\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.254\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.328\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJL 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.899\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.084\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.983\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJL 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.702\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.839\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJL 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.258\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eFigure Legends\u003c/b\u003e :\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAccording to the data in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, FW and basic measurements (ATJL, MEJL, LEJL) are highly influenced by demographic factors and are limited in terms of stability.Normalized ratios (especially ATJL/FW) and combined indices (JL AF, JL Combine, JL Symmetry, JL 3) emerged as the most reliable measures with low StabilityScore values.Specifically, JL 3 and JL AF/Combined indices have been identified as the most stable indicators, independent of demographic factors and with a low coefficient of variation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe most important finding of this study is that Basic anatomical measurements used to determine JL, such as FW, ATJL, FHJL, MEJL, and LEJL, are greatly affected by demographic variables and cannot be used alone to determine JL. The most reliable parameters for determining JL, which are least affected by demographic data, are ATJL/FW and JL 3.Furthermore, this study demonstrated that different indices previously defined in the literature as normalized ratios and considered reliable may vary depending on demographic data and therefore cannot be used reliably.\u003c/p\u003e\u003cp\u003eIacano and colleagues, in their study to identify methods that could be used to determine JL, compared radiographic measurements with intraoperative measurements[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. As a result, they found that the ATJL/FW ratio showed the highest agreement between radiographic measurement and intraoperative measurement.In their study evaluating full-leg standing x-rays of 100 healthy volunteers, Luyckx and colleagues demonstrated, similarly to the previous study, that the ATJL/FW ratio could be reliable and accurate for JL reconstruction, particularly in revision total knee arthroplasty[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].Ak\u0026ccedil;a and colleagues also used both traditional and ratio-based methods to determine the JL in revision total knee arthroplasty ( ) in their study, where they compared their radiographic measurements with intraoperative measurements.In this study, which used data from 16 revision knee arthroplasty patients, the Adductor Tubercle-Ratios method was shown to be a more reliable and usable method for determining the JL[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Y\u0026uuml;ksel and colleagues, in a retrospective study involving 186 patients[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] stated that the AT is a reliable landmark for determining the JL[In another study, anatomical landmarks that could be used to determine the JL were evaluated comparatively. This study also stated that the AT is a suitable anatomical landmark for determining the JL in revision surgeries[[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]In another study, Iacona demonstrated that the ATJL/FW ratio can be appropriately used to determine the JL in revision knee surgeries using an intraoperative control method[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Unlike these radiographic and intraoperative measurements, Maderbacher and colleagues conducted an MRI-based study to determine the JL.In this study, different measurements of FH, AT, ME, and LE were used; as a result, they showed that a healthy JL restoration cannot be achieved with direct bone-based measurements and that an index such as \"6.40 + (width femur [mm] \u0026times; 0.49) to the AT\" can be used[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].In their study on JL determination in the Chinese population, Gao and colleagues stated that different formulations should be created for women and men for reliable JL detection and concluded that the formulation \"ATJL\u0026thinsp;=\u0026thinsp;0.562 \u0026times; FW\" could be used for women and \"ATJL\u0026thinsp;=\u0026thinsp;0.548 \u0026times; FW\" for men[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In their study using 50 X-rays taken with a standardized protocol, Xia and colleagues emphasized that AT is a reliable landmark and demonstrated that combinations with FW can be used[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].Fan and colleagues, in their study on the Chinese population, emphasized that ME and LE are also usable landmarks besides AT, but warned that ratios need to be established according to different races [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. There are numerous studies in the literature related to determining JL, which include different results, but most of them have not revealed the effect of demographic variables such as age, gender, and region.In contrast, our study has detailed the effects of these variables and determined how JL can be identified using parameters that are least affected by these variables. Although our study draws conclusions based on a broader analysis than other studies, it is not possible to know the natural JL of every individual.Therefore, as stated by Hirschmann et al[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], larger databases should be created and a transition to personalized medicine should be made, using individualized values for coronal plane deformity analysis and preoperative planning.\u003c/p\u003e\u003cp\u003e This study is methodologically robust due to its multicenter, large, and balanced sample (n\u0026thinsp;=\u0026thinsp;3000; 10 countries), standard AP imaging following a single protocol (SID\u0026thinsp;=\u0026thinsp;100 cm, full extension, no rotation), strict exclusion criteria, and use of the average measurements of two observers; beyond the p-value, it systematically maps effect size (η\u0026sup2;, d) and CoV with demographic sensitivity, defines JL3 and other composite/normalized indices in addition to literature ratios, and provides an applicable framework for a demographic-resistant decision metric. However, the design is retrospective-cross-sectional, lacks external validation with intraoperative/clinical outcomes, does not assess observer reliability (ICC); despite symmetry filters, there is a risk of rotation/collimation artifacts and magnification differences between devices despite SID standardization; KL 3\u0026ndash;4 and BMI\u0026thinsp;\u0026gt;\u0026thinsp;30 exclusions limit generalizability.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eConsequently, basic measurements such as ATJL, FHJL, MEJL, LEJL, and FW, which are performed using direct landmarks, should not be used for JL detection because they show significant variations depending on demographic parameters. The ATJL/FW and JL 1 indices, which are the parameters least affected by demographic data, can be used reliably together or separately for JL detection.However, both primary and revision surgeries require broader and more personalized data for the anatomical restoration of JL.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements :\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e The authors declare that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e Ethical approval has been obtained and will be uploaded as an additional file.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent:\u003c/strong\u003e This study is a retrospective screening study; informed consent was not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSA, ID, MU, SAJ, LA, AR, MF, MZ, AY, FF, EP, MBLV, ALB, JGP, DRR, DS, JI, KH, NG, GA, MFD, and MC contributed to study design and data collection.\u003c/p\u003e\n\u003cp\u003eSA and ID developed the theoretical framework, performed analytic calculations, and contributed to data interpretation.\u003c/p\u003e\n\u003cp\u003eMU contributed to data analysis and manuscript preparation.\u003c/p\u003e\n\u003cp\u003eMC supervised the overall project.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAk\u0026ccedil;a M\u0026Ccedil;, Akalın Y, \u0026Ccedil;evik N, Şahin İG, Avcı \u0026Ouml;, \u0026Ouml;zt\u0026uuml;rk A (2020) Joint line reestablishment in revision total knee arthroplasty. 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Knee Surg Sports Traumatol Arthrosc 21(12):2725\u0026ndash;2729\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIacono F, Raspugli GF, Filardo G, Bruni D, Zaffagnini S, Bignozzi S, Lo Presti M, Akkawi I, Neri MP, Marcacci M (2016) The adductor tubercle: an important landmark to determine the joint line level in revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 24(10):3212\u0026ndash;3217\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJawhar A, Wasnik S, Scharf HP, Roehl H (2014) The fibula head is a useful landmark to predict the location of the posterior cruciate ligament footprint prior to total knee arthroplasty. Int Orthop 38(2):267\u0026ndash;272\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eK\u0026ouml;nig C, Sharenkov A, Matziolis G, Taylor WR, Perka C, Duda GN, Heller MO (2010) Joint line elevation in revision TKA leads to increased patellofemoral contact forces. J Orthop Res 28(1):1\u0026ndash;5\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLuyckx T, Beckers L, Colyn W, Vandenneucker H, Bellemans J (2014) The adductor ratio: a new tool for joint line reconstruction in revision TKA. Knee Surg Sports Traumatol Arthrosc 22(12):3028\u0026ndash;3033\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLuyckx T, Beckers L, Colyn W, Vandenneucker H, Bellemans J (2014) The adductor ratio: a new tool for joint line reconstruction in revision TKA. Knee Surgery, Sports Traumatology, Arthroscopy 22(12):3028\u0026ndash;3033\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaderbacher G, Keshmiri A, Schaumburger J, Springorum HR, Zeman F, Grifka J, Baier C (2014) Accuracy of bony landmarks for restoring the natural joint line in revision knee surgery: an MRI study. Int Orthop 38(6):1173\u0026ndash;1181\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMartin JW, Whiteside LA (1990) The influence of joint line position on knee stability after condylar knee arthroplasty. Clin Orthop Relat Res\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePang HN, Yeo SJ, Chong HC, Chin PL, Chia SL, Lo NN (2013) Joint line changes and outcomes in constrained versus unconstrained total knee arthroplasty for the type II valgus knee. Knee Surg Sports Traumatol Arthrosc 21(10):2363\u0026ndash;2369\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePartington PF, Sawhney J, Rorabeck CH, Barrack RL, Moore J (1999) Joint line restoration after revision total knee arthroplasty. Clin Orthop Relat Res\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRomero J, Seifert B, Reinhardt O, Ziegler O, Kessler O (2010) A useful radiologic method for preoperative joint-line determination in revision total knee arthroplasty. Clin Orthop Relat Res 468(5):1279\u0026ndash;1283\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRyu J, Saito S, Yamamoto K, Sano S (1993) Factors influencing the postoperative range of motion in total knee arthroplasty. Bull Hosp Jt Dis 53(3):35\u0026ndash;40\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eServien E, Viskontas D, Giuffr\u0026egrave; BM, Coolican MRJ, Parker DA (2008) Reliability of bony landmarks for restoration of the joint line in revision knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 16(3):263\u0026ndash;269\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eServien E, Viskontas D, Giuffr\u0026egrave; BM, Coolican MRJ, Parker DA (2008) Reliability of bony landmarks for restoration of the joint line in revision knee arthroplasty. 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Arch Orthop Trauma Surg 126(7):480\u0026ndash;486\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXiao J, Wang S, Chen W, Yang Y, Liu T, Zuo J (2017) A Study to Assess the Accuracy of Adductor Tubercle as a Reliable Landmark Used to Determine the Joint Line of the Knee in a Chinese Population. J Arthroplasty 32(4):1351\u0026ndash;1355\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYeh KT, Chen IH, Wang CC, Wu WT, Liu KL, Peng CH (2019) The adductor tubercle can be a radiographic landmark for joint line position determination: an anatomic-radiographic correlation study. J Orthop Surg ResDOI. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/S13018-019-1221-Y\u003c/span\u003e\u003cspan address=\"10.1186/S13018-019-1221-Y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoshii I, Whiteside LA, White SE, Milliano MT (1991) Influence of prosthetic joint line position on knee kinematics and patellar position. J Arthroplasty 6(2):169\u0026ndash;177\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eY\u0026uuml;ksel Y, Akar MS (2025) Adductor tubercle as a reliable landmark for knee joint line determination: a comparative radiological study. Arch Orthop Trauma SurgDOI. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/S00402-025-06031-3\u003c/span\u003e\u003cspan address=\"10.1007/S00402-025-06031-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"joint line, knee arthroplasty, adductor tubercle, normalized ratio, composite index, multicenter radiography","lastPublishedDoi":"10.21203/rs.3.rs-8278547/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8278547/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e:To quantify how sex, age, and region affect radiographic joint-line (JL) measurements and indices on standardized AP knee radiographs across ten countries, and to identify a demography-resistant metric set for reliable JL restoration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e:Multicenter retrospective study of\u003cstrong\u003e3,000 \u003c/strong\u003eAP knee radiographs (1,500 female/1,500 male; ages 20–79) from\u003cstrong\u003e 10 countries\u003c/strong\u003e. Standardized acquisition (SID 100 cm; AP, full extension, no rotation). Exclusions: prior peri-knee fracture/surgery, KL 3–4 OA, neurovascular deficit, septic arthritis, rheumatologic disease, BMI \u0026gt; 30, inadequate AP. Measurements: \u003cstrong\u003eATJL, FHJL, MEJL, LEJL, FW. \u003c/strong\u003eDerived indices: literature-based \u003cstrong\u003eATJL/FW, FHJL/FW, MEJL/FW, LEJL/FW, JL1, JL2; \u003c/strong\u003enewly defined \u003cstrong\u003eJL-AF, JL-Combine, JL-Symmetry, JL-Ratio, JL3. \u003c/strong\u003eStatistics: t-tests, one-/two-way ANOVA, multiple regression; effect sizes (\u003cstrong\u003eCohen’s d, η²)\u003c/strong\u003e; variability (\u003cstrong\u003eCoV)\u003c/strong\u003e. α=0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e:Men showed higher FW (92.83 ± 11.15 vs 81.38 ± 8.54), ATJL (52.16 ± 6.31 vs 46.07 ± 5.46), FHJL (20.74 ± 4.05 vs 19.13 ± 4.04), MEJL (38.22 ± 8.96 vs 34.62 ± 7.67), and LEJL (35.35 ± 8.90 vs 32.07 ± 7.64); all \u003cstrong\u003ep\u0026lt;0.001. \u003c/strong\u003eWith aging, \u003cstrong\u003eFHJL, MEJL, and LEJL \u003c/strong\u003edecreased (p \u0026lt; 0.001); \u003cstrong\u003eFW and ATJL \u003c/strong\u003eshowed no relevant age effect (p \u0026gt; 0.05). \u003cstrong\u003eRegion \u003c/strong\u003estrongly impacted all variables (largest η²: \u003cstrong\u003eLEJL 0.583, MEJL 0.561, FW 0.493)\u003c/strong\u003e. Among derived metrics, \u003cstrong\u003eATJL/FW \u003c/strong\u003e(η² = 0\u003cstrong\u003e.016, \u003c/strong\u003eCoV = 0.228) and \u003cstrong\u003eJL3 \u003c/strong\u003e(η² = 0\u003cstrong\u003e.023, \u003c/strong\u003eCoV = 0.235) were the \u003cstrong\u003emost stable across demographics. \u003c/strong\u003eJL-AF (η² = 0.036), JL-Combine (0.028), and JL-Symmetry (0.028) were low-dependency validators. \u003cstrong\u003eFW-based JL1 \u003c/strong\u003e(η² = 0.899) and \u003cstrong\u003eJL2 \u003c/strong\u003e(0.702) were \u003cstrong\u003edemography-sensitive \u003c/strong\u003eand unreliable as stand-alone predictors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e:Basic anatomic distances are \u003cstrong\u003edemography-dependent \u003c/strong\u003eand poor single guides for JL restoration. A \u003cstrong\u003enormalize-and-combine \u003c/strong\u003estrategy—using \u003cstrong\u003eATJL/FW \u003c/strong\u003eas the anchor and \u003cstrong\u003eJL3 \u003c/strong\u003eas the composite confirmatory index (optionally cross-checked by JL-AF/JL-Combine/JL-Symmetry)—provides \u003cstrong\u003erobust, transferable \u003c/strong\u003eradiographic estimation across centers. \u003cstrong\u003eAvoid single-variable FW models \u003c/strong\u003e(e.g., JL1) in routine planning. Larger, population-level datasets should support personalized thresholds.\u003c/p\u003e","manuscriptTitle":"Standardizing Joint-Line Determination on Anteroposterior Knee Radiographs: Multicenter Validation of the Adductor Ratio and a Novel Composite Index in 3,000 Knees","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-15 16:15:31","doi":"10.21203/rs.3.rs-8278547/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-18T11:20:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T13:34:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"160381351948341245463360581856194604313","date":"2025-12-11T13:24:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267759278062818826997965635481811336329","date":"2025-12-09T19:26:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-09T18:29:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-06T10:51:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-06T10:51:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2025-12-04T10:59:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6c485f4d-c1b6-4cbd-ad47-1b42b882c243","owner":[],"postedDate":"December 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:04:30+00:00","versionOfRecord":{"articleIdentity":"rs-8278547","link":"https://doi.org/10.1007/s00402-025-06185-0","journal":{"identity":"archives-of-orthopaedic-and-trauma-surgery","isVorOnly":false,"title":"Archives of Orthopaedic and Trauma Surgery"},"publishedOn":"2026-02-02 15:59:44","publishedOnDateReadable":"February 2nd, 2026"},"versionCreatedAt":"2025-12-15 16:15:31","video":"","vorDoi":"10.1007/s00402-025-06185-0","vorDoiUrl":"https://doi.org/10.1007/s00402-025-06185-0","workflowStages":[]},"version":"v1","identity":"rs-8278547","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8278547","identity":"rs-8278547","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}